Brain diseases: Substance abuse and co-occurring disorders Mark Publicker, MD FASAM.
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Transcript of Brain diseases: Substance abuse and co-occurring disorders Mark Publicker, MD FASAM.
Brain diseases: Substance abuse and co-occurring disorders
Mark Publicker, MD FASAM
Addiction
• A chronic but treatable brain disease characterized by• Loss of control• Compulsive use• Use despite known harm• Relapse• The emergence of a negative affect state
Questions
Does mental illness cause substance abuse?
Does substance abuse cause mental illness?
Questions
Are there differences in populations Primarily psychiatric Primarily substance dependent
Comorbid substance abuse
Common problem in psychiatric patients
Contributes to treatment failure and non-compliance
Increased health care costs
Neurobiology
Same neurotransmitter systems Dopamine Serotonin GABA Glutamate Endogenous opioids
Neurobiology
Drugs of abuse interact and alter neural substrates of psychiatric disorders
More neuro-psychological impairment
Rand Survey 2001
3% US population has co-occuring disorders
Of these: 72% received no treatment in
previous 12 months Only 8% received both mental and
substance abuse treatment Only 23% of those in treatment
received “appropriate treatment”
Current situation in US treatment systems
Comorbid rates are high Different services are provided
according to entry portal
Co-morbid psychiatric disorders
Depression Anxiety disorders Bipolar disorder Schizophrenia
Co-morbid psychiatric disorders
Attention deficit hyperactivity disorder
Post traumatic stress disorder Antisocial personality disorder
Epidemiology substance abuse disorders
50% lifetime prevalence for psychiatric patients
Among individuals with alcohol use disorders, about 22% will also have a drug use disorder
Among individuals with a drug use disorder, almost half (47%) will have an alcohol use disorder
Schizophrenia: 70%prevalence rates Earlier onset of symptoms
Epidemiology Affective disorders are very common. Up to
67% of alcohol-dependent patients, 53% of cocaine-dependent patients, and 75% of opiate-dependent patients have comorbid affective disorders
Approximately 25-50% of alcohol dependent individuals meet criteria for an anxiety disorder
Approximately 30-60% of patients with an SUD have comorbid Antisocial Personality Disorder
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Order of Onset Mental disorders typically emerge before
comorbid substance use disorders
This pattern is somewhat stronger for women than men
Data from a large epidemiologic study found that the median age of onset of mental disorders was 11 yrs old as compared to 21 yrs old for substance disorder
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Diagnostic Difficulties
Substance intoxication and withdrawal can mimic nearly any psychiatric disorder
Stimulants/hallucinogens/cannabinoids= mania and schizophreniaAlcohol/opiate/sedative-hypnotic
withdrawal= depressive and anxiety disorder
Diagnostic Difficulties Assess which disorder developed first
Ask about symptoms during periods of abstinence. Minimum acceptable period of abstinence necessary for diagnostic clarity will differ by diagnosis:
Anxiety/depression: most symptom overlap, 2-4 weeks important.
Psychosis/mania 2-4 days sufficient in most cases.Ask about family history
Consult multiple sources of information
Substance Use and SuicideSubstance Use and Suicide
Substance induced depressionSubstance induced depression May resolve quickly with treatment but is May resolve quickly with treatment but is
still very dangerousstill very dangerous Increased suicidal thoughts, ideationIncreased suicidal thoughts, ideation
High risk group: Diagnosis of major High risk group: Diagnosis of major depression + alcohol or drug depression + alcohol or drug abuse/dependenceabuse/dependence
Rates are 20-120X the general Rates are 20-120X the general populationpopulation
Epidemiology Schizophrenia: substance abuse
associated with higher rates of homelessness, non-compliance, medical illness and violence
Bipolar disorder: rates estimated to be 50-70% Associated with worse prognosis
Epidemiology
Unipolar depression: 30-50% Associated with treatment resistance and
greater severity Worsens alcohol dependence treatment
outcomes
Epidemiology
ADHD: 50% of substance abuse patients Increases risk of substance abuse Effective childhood treatment reduces
risk
Epidemiology PTSD: increased risk of substance abuse
Hypothalamic and noradrenergic mechanisms
Substance abuse increases PTSD symptoms which in turn intensify substance abuse
Post traumatic stress disorder Withdrawal symptoms overlap with arousal
symptoms Increased stress sensitizes the Locus Ceruleus
Post traumatic stress disorder
Increased noradrenaline increases stress
Increased fear responses in amygdala
Epidemiology - Nicotine Nicotine-dependent patients with
comorbid disorders: 7.1% US population consume 34.2% of all cigarettes smoked
Self-medication hypothesis
Nicotine decreases stress reactivity Schizophrenia: nicotine used to deal
with negative symptoms: Sleepiness Dysphoria Antipsychotic adverse effects Improve cognitive function
Cannabis
Heavy adolescent use increases psychiatric risk Depression Anxiety disorders Schizophrenia
Summary High rates of comorbidity Each increases the risk of the other and
complicates their management Concurrent treatment yields best results